Provider Demographics
NPI:1174761894
Name:JIMENEZ, ELIA (RDA)
Entity type:Individual
Prefix:MRS
First Name:ELIA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15913 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5103
Mailing Address - Country:US
Mailing Address - Phone:562-630-7012
Mailing Address - Fax:
Practice Address - Street 1:15913 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5103
Practice Address - Country:US
Practice Address - Phone:562-630-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37312126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant